New Patient Intake Form

In order for us to know how to serve you best, please take the time to honestly and accurately answer the following questions. Dr. Komeshak will personally review this information in order to prepare for your visit to our office.

How Can We Help You?

Current Health Status

Have you ever suffered from:

Have you ever:

Family History

Lifestyle Habits

Stress is a contributing factor in all health conditions. There are 3 major categories of stress: physical (the things we do), emotional (the way we think), and chemical (the things we consume, absorb, and breathe). The following questions are designed to determine how these types of stress are affecting your life.

Please rate your consumption of the following:

Additional Information

Enter the verification code in the box below.